How the ACA will affect people living with HIV/AIDS: Ensuring full implementation

How the ACA will affect people living with HIV/AIDS: Ensuring full implementation

Texas Gov. Rick Perry

The third in a series that examines the Affordable Care Act’s impact on people living with HIV/AIDS.

Although the Affordable Care Act’s (ACA) passage represented a potentially transformative moment in the nation’s three-decade-long struggle with AIDS, its promise has yet to be realized. To help lay a foundation for ending AIDS in the U.S., the ACA will need to be fully implemented.

Several potentially critical obstacles to full implementation will need to be overcome. First, each state must decide whether to expand its Medicaid program under the terms of the ACA or leave it as is, with broad exclusions of coverage for non-disabled adults. While the ACA, as originally adopted, made continued federal support for state Medicaid programs contingent on the state’s agreement to expand the program, the Supreme Court held that the federal government could not withhold all Medicaid funding from states that refuse to expand the program. As a result, the Medicaid expansion that is so critical to PLWHA is now an option for the states, not a requirement.

Several Republican state governors have announced their opposition to expanding Medicaid in their states. Opposition is most intense in the South, which is now the epicenter of the U.S. AIDS epidemic. Accounting for a third of the nation’s population, the South is home to nearly half of all people newly infected with HIV, with cases heavily concentrated in Black communities.

Is Medicaid Expansion an Expense or an Investment?

The opposition to Medicaid expansion is curious in some respects, since the ACA makes Medicaid expansion an exceedingly good bargain for the states. Under the ACA, the federal government pays for 100 percent of the costs of expanding Medicaid in 2014-2016, with the federal share of the cost falling to 90 percent in 2020 and beyond. This contrasts with other Medicaid costs, for which the federal share varies from 50 percent to nearly 75 percent, according to the Department of Health and Human Services.

Robert Greenwald, director of the Center for Health Law and Policy Innovation at Harvard Law School, notes that the reasons governors have given for opposing the Medicaid expansion vary. Notwithstanding the generous terms offered to states under the ACA, some governors have argued that the expansion would increase future spending obligations for states that are currently experiencing extreme financial distress.

Greenwald observes that the economic arguments against Medicaid expansion are weak. “For every dollar the states put in, the federal government will put in nine dollars,” he says. “This is federally funded business activity in states. The flip side is that the ACA cuts federal payments for uncompensated care in half, regardless of whether a state expands Medicaid or not. If you don’t embrace Medicaid expansion, you will have less money for uncompensated care.

“We need to acknowledge to the states that Medicaid expansion is an investment,” he adds. “But it will generally save money over time and will bring in huge amounts of revenue to the states.”

Some governors have questioned whether expanding Medicaid will improve health outcomes, arguing that so-called social determinants have more to do with health results than health-care access. This argument ignores not only substantial evidence that Medicaid coverage improves health outcomes for low-income individuals and families but also the reality that inadequate health-care access is itself a social determinant.

Other opponents of expansion argue that Medicaid is a “broken system” that should be scrapped rather than expanded. While traditional Medicaid has long had problems, Greenwald notes that under the ACA, Medicaid is “actually an entirely new program.” The ACA transitions Medicaid from a disability-based program to a healthcare program that prioritizes prevention.

The Importance of Essential Health Benefits

If many states opt not to expand Medicaid, much of the promise of the ACA will be undermined for PLWHA. In particular, access to preventive and early-intervention health care will remain largely outside the mainstream public health-care system.

In addition to deciding whether to expand Medicaid, states will also have considerable say over which services are included in their essential health benefits package. Although the federal government issued guidance to states in 2012 on the development of a package, states will have substantial flexibility in designating the scope and level of services that Medicaid and private health plans will be required to cover.

“A lot of discretion is being left to the states on the essential benefits package,” Greenwald said. “In some states there will be robust benefit packages, and in other states there won’t.” This raises particular concerns with respect to people with HIV and other chronic conditions, who require costly coverage and innovative delivery strategies not needed by the typical patient. If state-determined essential benefits packages don’t mandate coverage of key services needed by PLWHA, the quality of HIV care will suffer and health disparities will persist.

The ultimate impact of the ACA will depend in large measure on whether individuals make use of the new health-care options available under the law. For any number of reasons—lack of information, misperceptions or life conditions that make accessing services difficult—many people from all walks of life fail to use the available health services. Community education will play a vital role in helping individuals understand the health-care options available to them and community service organizations will need to revise their approaches in order to assist their constituents in taking advantage of expanded health coverage. Because service systems and essential benefit packages will vary considerably, community education and support strategies will need to be tailored to individual settings.

Congressional decisions on the future of the Ryan White HIV/AIDS Program could also have an important influence on the ACA’s benefit to PLWHA. The program is due for reauthorization in 2013, and there is little doubt that it will need to adapt to the changes brought about by the ACA. Especially given the possibility that some states will adopt restrictive benefits packages, a revised program provides an ideal vehicle for supporting essential services that may not be covered in all states. In particular, an adapted Ryan White program could provide vital funding for innovative service models that link people to care, retain them in care, support them in adhering to their medications and educate them about treatment options.

Next week: Advocacy to Ensure Full Implementation of the ACA.

Excerpted from the Black AIDS Institute’s 2013 State of AIDS Report, “Light at the End of the Tunnel: Ending AIDS in Black America.”